A nurse is collecting data from child who has measles. Which of the following manifestations should the nurse expect to find?

Beefy, red tongue

Paroxysmal cough

Peeling of the hands and feet

Fever

Answer and Explanation

The Correct Answer is D

A) Beefy, red tongue: The beefy, red tongue is typically associated with scarlet fever, a bacterial infection caused by group A Streptococcus. This condition can lead to a red, "strawberry" tongue, often accompanied by a rash. While measles can involve a variety of symptoms, including a red rash, conjunctivitis, and cough, the beefy red tongue is not characteristic of measles. In measles, the more notable symptoms are a high fever, cough, runny nose, and the development of Koplik spots inside the mouth.

B) Paroxysmal cough: Paroxysmal cough, which is a sudden, severe, and uncontrollable cough often followed by a "whooping" sound, is more characteristic of pertussis (whooping cough). While a cough is indeed present with measles, it is generally not paroxysmal. In measles, the cough is more persistent and associated with other typical symptoms such as fever and a characteristic rash. The coughing in measles may also be dry and harsh but does not tend to occur in violent, paroxysmal episodes like those seen in pertussis.

C) Peeling of the hands and feet: Peeling of the skin, particularly of the hands and feet, is more commonly observed in conditions such as scarlet fever, Kawasaki disease, or after a viral infection like hand-foot-and-mouth disease. It is not a classic finding of measles. In measles, the skin rash usually starts as maculopapular spots on the face and spreads down the body. While some skin sloughing can occur after the rash resolves, especially in severe cases, it is not the characteristic sign of measles, and it is not typically seen on the hands and feet.

D) Fever: Fever is one of the earliest and most prominent symptoms of measles. It typically appears about 2-4 days before the characteristic measles rash. The fever in measles can be quite high, often exceeding 104°F (40°C), and is associated with other symptoms such as cough, conjunctivitis, and photophobia. The fever usually persists for several days, and it is one of the critical signs that lead to the diagnosis of measles, particularly when combined with the characteristic rash and other respiratory symptoms.

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Correct Answer is C

Explanation

A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure disorder unless they have specific feeding or aspiration concerns that require tube feeding. During a seizure, the priority is to ensure airway clearance and prevent injury, not necessarily to provide nutrition through an NG tube.

B) Tongue blade: It is a common myth that tongue blades should be used to prevent a client from biting their tongue during a seizure. However, using a tongue blade can be dangerous as it can cause injury to the mouth or teeth, or even cause choking. The nurse should never attempt to place anything in the client's mouth during a seizure.

C) Suction machine: A suction machine is essential for maintaining airway patency during or after a seizure. Clients with seizure disorders may be at risk for aspiration, and the suction machine can be used to clear secretions from the mouth to prevent choking or aspiration pneumonia. This is the most appropriate supply to place at the bedside.

D) Syringe containing lorazepam: While lorazepam (a benzodiazepine) is sometimes used for acute seizure management, it is not a routine item to have immediately at the bedside unless specifically ordered for emergency seizure intervention. The nurse should follow protocol and administer medications as prescribed, but a syringe of lorazepam is not typically pre-placed at the bedside.

A. Completely undress the toddler. B. Allow the toddler to handle the equipment. C. Start the examination with routine immunizations. D. Thoroughly explain each procedure to the toddler

Correct Answer is B

Explanation

A) Completely undress the toddler:
Completely undressing a toddler can cause unnecessary distress and anxiety, especially if they are not prepared for the examination. It’s more appropriate to undress the toddler only as needed for the physical exam and allow them to remain clothed or partially clothed whenever possible to help them feel secure.

B) Allow the toddler to handle the equipment:
Allowing a toddler to handle the medical equipment is an excellent way to reduce fear and anxiety. This familiarizes the child with the instruments and allows them to feel more in control of the situation. It also helps in building trust with the nurse, making the examination less intimidating for the toddler.

C) Start the examination with routine immunizations:
Immunizations can be particularly stressful for toddlers, so starting the examination with vaccines is not the best approach. It’s better to begin with non-invasive procedures, such as listening to the heart or measuring the toddler’s height and weight, to build rapport before proceeding to any painful procedures.

D) Thoroughly explain each procedure to the toddler:
While it’s important to explain the examination to the toddler in simple, age-appropriate language, toddlers typically have a limited understanding of detailed explanations. Over-explaining may increase anxiety. Instead, it's better to keep things brief and comforting, using simple phrases, and focus on creating a positive experience.

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Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A nurse is collecting data from child who has measles. Which of the following manifestations should the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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